Emollient prescribing guidelines 2023

Bath emollients support document 2023

Moisture Associated Skin Damage (MASD) Pathway

Emollient pathway

Fire risk with paraffin-containing products

Greasy preparations (ointments) are often preferable to creams in most circumstances because:

However, patient preference or activity may necessitate a combination of ointments and creams, for example, patients may prefer to apply creams during the day and use ointments at night, or different preparations on different parts of the body.

Application technique: It is important to educate patients with the correct application technique. Ointments and creams should be applied down the direction of hair growth. They should also be smeared on and not rubbed in.

Pot Hygiene: When supplying patients with pots of emollient, it is important to educate them about the hygiene required. Patients should be advised to decant from the pot onto plate/bowl etc. using a spoon or a spatula. Hands should not be put into the pot as this will lead to the introduction of foreign particles.

In many cases generic prescribing will be difficult because products contain a combination of active ingredients. In this chapter brand names are used for products which should not be prescribed generically.

Extemporaneous preparations: A product should only be extemporaneously prepared when there is no product with a marketing authorisation available. Depending on the formulation this may be done in a pharmacy, or by a specials manufacturer, usually depending on the formulation. Where a specials manufacturer prepares the product, additional charges will be incurred. The cost can, and usually does, exceed £100 for a cream. The cost is usually the same whether 500 g or 50 g of a product is ordered. Specials all have a very short shelf life with an expiry date of a maximum of 28 days from manufacture.

A range (but not all) of specials preferred by the British Association of Dermatologists has been approved for use within Cornwall mainly for prescribing by secondary care.

NICE Referral Advice for Acne, December 2001

Prior to treatment patients should be asked to subjectively grade the severity of their acne so that response to therapy can be measured. The GP should identify the morphology of the acne eg comedonal, inflammatory or nodulocystic (referral may be required). In mild comedonal acne use benzoyl peroxide whilst adapalene or tretinoin are to be preferred if more severe. For mild to moderate inflammatory acne progress from benzoyl peroxide to topical antibiotics to oral antibiotics depending upon the response. When prescribing benzoyl peroxide start with a low strength and increase if necessary. For patients with darker skin types it may be appropriate to initiate treatment with a higher strength of benzoyl peroxide. For severe inflammatory acne give appropriate antibiotics.

• Oxytetracycline, tetracycline or erythromycin should be given at a dose of 500 mg BD for about 3 months, then reassess. Continue with further one to three month course if response is good. If there is a poor response, try another oral antibiotic or add in Dianette® if patient is female.
• Lymecycline 408 mg daily is a more expensive option but is a once a day antibiotic.
• Additional contraceptive precautions are not required during or after courses of antibiotics that do not induce liver enzymes (Rifampicin-like drugs e.g. rifampicin, rifabutin are the only antibiotics that are enzyme inducers). However women should be advised about the importance of correct contraceptive practice during periods of illness, eg if the antibiotics (and/or the illness) caused vomiting or diarrhoea.
• Topical agents should be prescribed in addition to oral antibiotics.
• Minocycline is associated with a greater risk of lupus erythematosus-like syndrome. DTB Jan 09, 47:7-8 concludes that due to the lack of therapeutic advantage over tetracyclines and concerns over its safety it is no longer recommended for the treatment of acne.

Patients with more severe acne may require treatment with oral isotretinoin prescribed by a dermatologist in secondary care. Isotretinoin is teratogenic.

Rosacea is not comedonal (but may exist with acne which may be comedonal). The pustules and papules of rosacea respond to topical metronidazole (see Section 13:13) or to oral administration of oxytetracycline, tetracycline, or erythromycin (all at 500 mg BD for 6 - 12 weeks).